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Routine Immunization:
The Missed Child Perspective
Maya van den Ent, PharmD MPH
Edward Hoekstra, MD, MSc
David Brown, DSc, MScPH, MSc
Halima Dao, MD, MSc
Satish Gupta, MD
UNICEF
78
58
85
72
0
20
40
60
80
100
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Coverage Measles 1 st dose Global
Source: WHO/UNICEF immunization coverage for 2010
Coverage MCV1 Coverage MCV1 globally and in 47 priority countriesglobally and in 47 priority countries
UNICEF
2000
2005
2010
Number of countries (all countries)
MCV1 coverage 2000 2005 2010
<70% 37 36 26
70-79% 27 17 17
80-89% 44 31 24
90-99% 84 109 127
Source: WHO/UNICEF immunization coverage for 2010
MCV1 Coverage 2000 – 2010MCV1 Coverage 2000 – 201047 47 Priority CountriesPriority Countries
Human RightsHuman Rights
The Universal Declaration of Human Rights:based on the principle of human equality;
•everyone has right to equal access to public services in his or her country
•everyone has the right to a standard of living adequate for the health and well being of him/her and family, including food, clothing, housing, medical care and social services.
Child RightsChild Rights….
Convention on the Rights of the Child: four core principles: • non-discrimination• devotion to the best interests of
the child• the right to life, survival and
development• respect for the views of the child.
The poorest are more likely to dieThe poorest are more likely to die
Indonesia Indonesia Under 5 Mortality Rate by Wealth Quintiles 2002 - 2003Under 5 Mortality Rate by Wealth Quintiles 2002 - 2003
Proportion of children under 5 years who are underweight, by household wealth quintile
Progress for Children: Achieving the MDGs with Equity ; September 2010; NFHS-2005-06
Level of under - nutrition in children belonging to the poorest Level of under - nutrition in children belonging to the poorest households has remained stagnant for decadehouseholds has remained stagnant for decade
19.1 million infants not having received MCV1, 2010
CountryCoverage
# Infants no MCV1 (routine)
India 74 6,709,000
Nigeria 71 1,668,000
DR Congo 68 815,000
Uganda 55 630,000
Pakistan 86 619,000
Indonesia 89 468,000
Ethiopia 81 463,000
Afghanistan 62 458,000
South Africa 65 352,000
USA 92 342,000
Every seventh child not reached
% based on 887 reasons abstracted from 209 relevant articles
28%
7%
44%
21%
Under – vaccinated
55%
6%
12%
27%
Unvaccinated
FamilyCharacter-istics
ImmunizationSystems
ParentalAttitudesAnd Knowledge
% based on 33 reasons abstracted from 12 articles on unvaccinated children
Under vaccinated: Infants received at least one vaccine, but no DTP3 Un-vaccinated: Infants received no vaccine at all
Reasons for under- or un-vaccination
Percentage of children age 12-23 fully immunized
District Level Household Survey 2007-2008
India: Immunization coverage varies significantlyIndia: Immunization coverage varies significantly among different population categoriesamong different population categories
Source: DLHS 2007-08; children surveyed were between 12-23 months
India: Where are the unvaccinated? India: Where are the unvaccinated? Children not vaccinated with DPT3Children not vaccinated with DPT3
FI (DLHS-2)Below 3030 to 5050 to 7070 to 90Above 90
Data not available
FI (DLHS-2)Below 3030 to 5050 to 7070 to 90Above 90
Data not available
Wide intra-state variations
Source: DLHS 2007-08; children surveyed were between 12-23 months
India: Where are the India: Where are the unvaccinated ? unvaccinated ?
District - level percentage of fully immunized childrenDistrict - level percentage of fully immunized children
UNICEF
Poor EducationPoor Education
Mother no TT2+Mother no TT2+
Minority religionMinority religion
RuralRural
No Radio/TVNo Radio/TV
PoorPoor
Source: Swiss Tropical Institute 2010
India – Predictors India – Predictors Only at least one vaccine vs fully immunizedOnly at least one vaccine vs fully immunized
The poorest are more likely not to be immunizedThe poorest are more likely not to be immunized
Greater disparities Greater disparities between provinces between provinces
than rural urbanthan rural urban
UNICEF
- Measles Partnership explores ways to further strengthen routine immunization in 2012
- Plan for critical activities strengthening routine during SIA planning
How to Reach the Under-served How to Reach the Under-served
Possible links between SIAs and RIPossible links between SIAs and RI
UNICEF
Possible links between SIAs and RIPossible links between SIAs and RI
Coordination & accountability for results
Bottom-up Micro-planning
Training
Logistics Management• Cold chain assessment & maintenance
Advocacy and Social Mobilization• Evidence based• Use of community health workers (defaulter tracing)• Health education for caregivers
UNICEF
Possible links between SIAs and RIPossible links between SIAs and RI
AEFI monitoring and management
Surveillance
Monitoring and Evaluation• Supportive supervision• Monitoring charts• Review meetings feeding into new microplans• Rapid assessments
Source: Vijayaraghavan M, Health Policy 2006
Nationwide Measles Vaccination Coverage by Wealth Quintile, Kenya, 2002
Measles campaigns reach the poorest
Source: Vijayaraghavan M, et al. Health Policy 2007, 83: 27-36
• MCV1 coverage has steadily improved from 2000 - 2010
• 19.1 million children remain unreached in 2010
• Focus on under-served populations will have highest impact
ConclusionsConclusions